Cockeysville, MD

Broadmead

5-star overall rating with 5-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

13801 York Road, Cockeysville, MD

(443) 578-8020

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

70

Certified beds

Average residents

38

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1980-02-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.84

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

1.02

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.83

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

5.69

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

2.86

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

5.25

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

1.59

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

2.11

CMS adjusted RN staffing hours

Adjusted total hours

6.52

CMS adjusted total nurse staffing hours

Case-mix index

1.19

Higher values indicate more complex resident acuity

RN turnover

39%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

40%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

700

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

65.14

Composite VBP score used to determine payment impact.

Payment multiplier

1.0194

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.37

Baseline 16.56% · Performance 18.95% · Measure score 5.37 · Achievement 5.37 · Improvement 0

Healthcare-associated infections

8.26

Baseline 6.22% · Performance 5.37% · Measure score 8.26 · Achievement 8.26 · Improvement 6.47

Total nurse turnover

2.43

Performance 53.73% · Measure score 2.43 · Achievement 2.43 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

10

Performance 7.77 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.55%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 432 · Observed rate 7.64% · Lower 95% interval 8.25%
Discharge to community	70.25%	50.57% 19.7 pts better	Better than the National Rate · Eligible stays 421 · Observed rate 73.87% · Lower 95% interval 67.16%
Medicare spending per beneficiary	0.66	1.02 0.4 pts better
Drug regimen review with follow-up	99.56%	95.27% 4.3 pts better	Numerator 228 · Denominator 229
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 229
Discharge self-care score	67.63%	53.69% 13.9 pts better	Numerator 140 · Denominator 207
Discharge mobility score	53.14%	50.94% 2.2 pts better	Numerator 110 · Denominator 207
Pressure ulcers or injuries, new or worsened	3.06%	2.29% 0.8 pts worse	Numerator 7 · Denominator 229 · Adjusted rate 3.54%
Healthcare-associated infections requiring hospitalization	5.37%	7.12% 1.8 pts better	No Different than the National Rate · Eligible stays 261 · Observed rate 2.68% · Lower 95% interval 3.17%
Staff COVID-19 vaccination coverage	40.06%	8.2% 31.9 pts better	Numerator 141 · Denominator 352
Staff flu vaccination coverage	99.45%	42% 57.5 pts better	Numerator 362 · Denominator 364
Discharge function score	59.42%	56.45% 3 pts better	Numerator 123 · Denominator 207
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 172 · Denominator 172
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 38 · Denominator 38
Resident COVID-19 vaccinations up to date	29.81%	25.2% 4.6 pts better	Numerator 31 · Denominator 104

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.8	1.3 0.5 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.9 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.8	1.2 0.4 pts better	1.8 1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	91.9% 6.9 pts better	93.4% 5.4 pts better	Long Stay · 2024Q4-2025Q3 · Q2 100.0% · Q3 100.0% · Q4 95.5% · 4Q avg 98.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.7%	96.6% 0.9 pts worse	95.5% 0.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	2.3% 2.3 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	10.7%	21.4% 10.7 pts better	11.4% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q3 10.0% · Q4 5.0% · 4Q avg 10.7%
Percentage of long-stay residents who lose too much weight	3.1%	5.7% 2.6 pts better	5.4% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	1.5%	16.1% 14.6 pts better	19.6% 18.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5%
Percentage of long-stay residents who received an antipsychotic medication	4.1%	15.3% 11.2 pts better	16.7% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.6%	26.6% 8 pts better	16.3% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	21.2%	22.9% 1.7 pts better	14.9% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.4%	0.7% 1.7 pts worse	1.0% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.4%	1.5% 0.9 pts worse	1.7% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.8% · Q4 4.5% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.7%	25.4% 3.3 pts worse	19.8% 8.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 28.7%
Percentage of long-stay residents with pressure ulcers	12.7%	6.3% 6.4 pts worse	5.1% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q2 22.0% · Q3 14.3% · Q4 7.1% · 4Q avg 12.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.7%	78.4% 19.3 pts better	81.7% 16 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 98.5% · Q3 97.6% · Q4 97.7% · 4Q avg 97.7%
Percentage of short-stay residents who had an outpatient emergency department visit	9.8%	9.9% 0.1 pts better	12.0% 2.2 pts better	Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 8.5% · Expected 9.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.0%	1.3% 0.3 pts better	1.6% 0.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	79.9%	80.6% 0.7 pts worse	79.7% 0.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 79.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	16.5%	21.2% 4.7 pts better	23.9% 7.4 pts better	Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 11.1% · Expected 16.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-03-21 · Fire 2024-03-21

4 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2019-04-19 · Fire 2019-04-19

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2017-12-21 · Fire 2017-12-21

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-03-21

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-06-17

F · Potential for more than minimal harm 2024-03-21

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-06-17

F · Potential for more than minimal harm 2024-03-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-17

E · Potential for more than minimal harm 2024-03-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-06-17

D · Potential for more than minimal harm 2024-03-21

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-06-17

D · Potential for more than minimal harm 2024-03-21

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-06-17

F · Potential for more than minimal harm 2019-04-19

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-07-08

F · Potential for more than minimal harm 2019-04-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-07-08

D · Potential for more than minimal harm 2019-04-19

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-07-08

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-03-21

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-04

D · Potential for more than minimal harm 2024-03-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-05-04

D · Potential for more than minimal harm 2024-03-21

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-05-04

D · Potential for more than minimal harm 2024-03-21

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-05-04

D · Potential for more than minimal harm 2019-04-19

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2019-05-12

D · Potential for more than minimal harm 2019-04-19

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-05-12

D · Potential for more than minimal harm 2017-12-21

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2018-01-30

D · Potential for more than minimal harm 2017-12-21

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2018-01-30

D · Potential for more than minimal harm 2017-12-21

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2018-01-30

D · Potential for more than minimal harm 2017-12-21

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2018-01-30

Penalties and ownership